URINARY TRACT INFECTION FOLLOWING RITUAL JEWISH
CIRCUMCISION

Michael Goldman, Joseph Barr, Tsvy Bistritzer and
Mordechay Aladjem

ABSTRACT: Circumcision seems to reduce the over
all incidence of urinary tract infections (UTI) although a
few studies have suggested that ritual circumcision may be
a predisposing factor for UTI within the first few weeks
following the procedure. The aim of this study was to
investigate a possible causal relationship between ritual
circumcision and UTI. The study comprised 82 infants with
UTI, 55 females and 27 males under the age of 1 year. All
males were circumcised on the eight day of life. The median
age of infection was 0.75 and 7.0 months for males and
females respectively. Fifty-two percent (14/27) of UTI were
diagnosed within 2 weeks following circumcision. A
significantly lower incidence in Escherichia
coli-induced UTI was observed in males compared with
females, 67% and 93% respectively. Similarly, the incidence
of E. coli-induced UTI was significantly lower in
males presenting within 2 weeks following the procedure
(92%). Positive blood cultures of an identical
microorganism were observed in 6/27 males compared to 2/55
females. The incidence of urinary tract malformations and
their severity were similar in both sexes. We conclude that
the high incidence of UTI following a ritual Jewish
circumcision, as well as the relative high preponderance of
bacteria other than E. coli, may suggest a causal
relationship between circumcision and UTI.

Urinary tract infection (UTI) in early infancy is often
associated with septicemia 1-4,
kidney scarring and occasionally renal failure5,6. During early infancy, male are more
commonly affected, but later on females predominate 7,8. Circumcision seems to reduce the
overall incidence of UTI in male infants 1,2,9-11. In Jewish neonates,
circumcision is performed routinely on the eighth day of life
by a ritual circumciser who is usually not a physician.
However, a few studies have suggested that ritual
circumcision may be a disposing factor for UTI within the
first 2 weeks following the surgical procedure 12-15. The aim of this study was to
evaluate the possible association of UTI with ritual
circumcision.

Methods
During a 4 year period, from April 1989 through April 1993,
82 infants under the age of 1 year were admitted with acute
UTI to the pediatric department at Assaf Harofeh Medical
Center. We included only Jewish females and circumcised male
infants; all of the male infants had been circumcised on the
eighth day of life. All infants had suprapubic aspiration,
and UTI was defined as 103 or
more colony forming units of a single microorganism.
Urosepsis was defined when blood and urine cultures were
positive for an identical microorganism. Only infants who had
both voiding cysto-urethrography and renal ultra-sound or
intravenous pyelogram were included in the study.

Data were analyzed using Χ2 analysis or Student's τ test. We
considered a P value of <0.05 to be statistically
significant.

Results
During the study period 82 hospitalized infants (55 females,
27 males) fulfilled our inclusion criteria. The mean age of
the male infants was signifantly younger than that of the
female infants (1.2 vs. 7 months, P<0.0001)(Fig.
1). The median age was 0.75 and 7.0, respectively. In the
majority of males, UTI occurred during the first month of
life (Fig. 2). The peak incidence was in the initial 13 days
following circumcision), and 52% (14/27) of the UTI episodes
occurred during that period. In females, the UTI episodes
were distributed evenly throughout the first year of
life.

Urine cultures revealed Escherichia coli in 84%,
Klebsiella in 11%, and other bacteria (Proteus,
Staphylococcus aureaus, Acienetobacter and
Pseudomonas aeruginosa) in 5% (Fig. 3). When we
compared the relative prevalence of E. coli versus
other bacteria in males and females we found a significantly
higher proportion of E. coli in females compared with
males. (93 vs. 67%, P<0.01) (Fig. 4). The incidence
of UTI induced by microorganisms other than E. coli was
significantly higher (P<0.01) in male infants
presenting within 2 weeks following circumcision (43%, 6/14)
than in the remaining males (8%, 1/13) or in all female
infants (7%, 4,55). Blood cultures were positive (identical
microorganism as in urine culture) in 6/27 males and 2/55
females (P<0.01). All males with positive blood
cultures were between 0.5 and 1.75 months old; four of them
had positive cultures within the 2 weeks following
circumcision. The two female infants were 4 and 8 months
old.

Vesico-urethral reflux was demonstrated in 9/27 males and
in 24/55 females. Seventeen males and 33 females had an
intravenous pyelography (IVP). Hydronephosis with or without
hydro-ureters was observed in 4/17 males and 6/33 females. A
renal ultrasound (US) was performed in 22 males and 34
females. Hydronephosis was found in 6/22 males and 5/33
females. The only structural anomaly observed in our
population with UTI was vesico-urethral reflux. Its incidence
and severity (degree of reflux was similar in both sexes.

Fig. 1 Age distribution of children under the age of
1 year with urinary tract infection

Fig. 2 Age distribution of children under the age of
2 months with urinary tract infection.

Fig. 3 Results of urinary tract bacterial culture in
82 children under the age of 1 year with urinary tract
infection.

Fig. 4 Relative growth of E. coli vs. other bacteria
in 27 males and 55 females under the age of 1 year with
urinary tract infection.

Discussion
Urinary tract infection is one of the most common diseases
in infancy. During the neonatal period, males seem to be more
commonly affected, whereas later on females predominate
6,7. In our study, 20 of 27
males, compared to only 2 of 55 females, suffered from UTI
during the first 4 weeks of life. Four infants of each sex
contracted UTI during the second month of life. Later on,
female infants predominated by far. The higher incidence of
neonatal UTI in males has been attributed by some authors to
an increased incidence of structural abnormalities 16,17. In our study, the single urinary
tract malformation observed was vesico-ureteral reflux, whose
incidence and severity were similar in both sexes.

Based on epidemeologic studies, it has been suggested that
neonatal circumcision may reduce the overall incidence of UTI
early infancy 1,2 9-11. It has
been hypothesized that the preputial fold, which is not
amenable to ordinary cleaning, may harbor vast quantities of
microorganisms that cause a contamination of the male urethra
with fecal flora.

Circumcision is faithfully performed in Jewish infants. It
is carried out on the eighth day of life unless medically
contraindicated, and is performed by a ritual circumciser.
Therefore, evaluating the incidence of UTI and its time of
occurence in circumcised and uncircumcised populations is
impossible in our area. However, comparing our data and those
published by others in Israel 12-14 with studies performed in
uncircumcised infants 7,18,19,
it seems that UTI develops at a younger age in ritually
circumcised infants than in intact ones. Wiswell et al.
18 followed 1,919 circumcised
male infants in whom 4 (0.21%) had UTI. The mean age of the
infection was 1.4 and 1.7 months, respectively. In the
present study, the mean age of UTI was 1.2 months. There was
no clinical evidence of pre-existing infection prior to
circumcision in any of the infants who developed UTI shortly
after the procedure. The clustering of UTIs in the 2 weeks
following the procedure may reflect a causal relationship
between UTI and ritual circumcision relative to the
non-sterile techniques used during the procedure, and may
also be in part due to a pain-induced urine retention
occurring immediately following circumcision. The significant
difference in bacterial pathogens between male infants
presenting with UTI within 2 weeks following circumcision and
both the remaining male infants and the female population may
also suggest a different etiology for the development of the
disease.

The combination of UTI and bacteremia is more common in
the newborn than later on in infancy 3,7,20. The relatively common episodes
of septicemia in male compared to female infants in our study
may simply reflect the earlier appearance of the UTI. However
a surgical procedure, albeit a minor one, performed under not
strictly sterile conditions, in an area not amenable to
ordinary cleaning and harboring great quantities of mainly
fecal microorganisms may also predispose to the development
of UTI and bacteremia.

In conclusion, it seems to us
that the high incidence of UTIs following ritual Jewish
circumcision, as well as the significant difference in
bacterial etiology, may suggest a causal relationship between
UTI and circumcision. A stricter sterile technique by
the ritual circumciser may reduce the risk.